From the Guidelines
Cardiac Extracorporeal Membrane Oxygenation (ECMO) is necessary in severe bupropion (Wellbutrin) overdose cases because it provides life-saving circulatory and respiratory support when conventional treatments fail, as supported by the 2023 American Heart Association guidelines 1. Bupropion overdose can cause severe cardiovascular toxicity, including refractory hypotension, malignant arrhythmias, and cardiac arrest that does not respond to standard resuscitation measures. The drug's unique toxicity profile stems from its inhibition of norepinephrine and dopamine reuptake, as well as its ability to block sodium and potassium channels in cardiac tissue, leading to QRS prolongation, QT interval extension, and potentially fatal dysrhythmias. Some key points to consider in the management of bupropion overdose include:
- The use of VA-ECMO for poisoning is increasing, with studies showing improved survival rates compared to standard care alone 1.
- VA-ECMO provides temporary mechanical circulatory support, maintaining organ perfusion while allowing time for the drug to be metabolized and eliminated from the body.
- The efficacy of VA-ECMO is particularly valuable in cases where the overdose lacks a specific antidote, and treatments like sodium bicarbonate, lipid emulsion therapy, and vasopressors may prove insufficient in severe cases.
- ECMO essentially creates a bridge to recovery by supporting vital organ function until the drug's toxic effects naturally subside, with observational studies showing reduced mortality compared to standard care alone 1. Key considerations for the use of ECMO in bupropion overdose include:
- The potential risks of significant complications, including limb ischemia, bleeding, stroke, and infection 1.
- The importance of early initiation of VA-ECMO in patients with refractory cardiogenic shock or cardiac arrest due to poisoning, as supported by the 2023 American Heart Association guidelines 1.
From the FDA Drug Label
10 OVERDOSAGE
- 1 Human Overdose Experience Overdoses of up to 30 grams or more of bupropion have been reported. Seizure was reported in approximately one third of all cases Other serious reactions reported with overdoses of bupropion alone included hallucinations, loss of consciousness, mental status changes, sinus tachycardia, ECG changes such as conduction disturbances or arrhythmias, clonus, myoclonus, and hyperreflexia Fever, muscle rigidity, rhabdomyolysis, hypotension, stupor, coma, and respiratory failure have been reported mainly when bupropion was part of multiple drug overdoses. Although most patients recovered without sequelae, deaths associated with overdoses of bupropion alone have been reported in patients ingesting large doses of the drug Multiple uncontrolled seizures, bradycardia, cardiac failure, and cardiac arrest prior to death were reported in these patients.
Cardiac Extracorporeal Membrane Oxygenation (ECMO) may be necessary in cases of severe bupropion (Wellbutrin) overdose due to the risk of cardiac failure and cardiac arrest. These conditions can lead to inadequate oxygenation of the blood, which ECMO can help support.
- Cardiac failure and cardiac arrest are life-threatening conditions that require immediate medical attention.
- ECMO can provide temporary support for the heart and lungs, allowing them to recover from the overdose. 2
From the Research
Cardiac ECMO in Bupropion Overdose
- Cardiac Extracorporeal Membrane Oxygenation (ECMO) is necessary in cases of severe bupropion (Wellbutrin) overdose due to the drug's potential to cause cardiotoxicity, including refractory cardiogenic shock, cardiac arrest, and arrhythmias 3, 4.
- Bupropion inhibits the uptake of dopamine and norepinephrine, leading to clinical effects such as seizure, status epilepticus, tachycardia, and cardiogenic shock 3.
- ECMO has been successfully used to treat patients with severe bupropion toxicity, including those with refractory cardiogenic shock, cardiac arrest, and repeated seizures 3, 4, 5.
- The use of ECMO in bupropion overdose is thought to be effective due to its ability to provide hemodynamic support and allow for the recovery of cardiac function 4, 5.
Indications for ECMO in Bupropion Overdose
- Severe cardiogenic shock refractory to medical therapy 3, 4, 5
- Cardiac arrest 3, 6
- Profound cardiovascular instability refractory to medical therapy 7
- High-dose bupropion ingestion (>750 mg/kg) 5